Petition to reduce resident work hours

[wild0ne]

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http://wakeupdoctor.org/

From an article in Modern Physician:

"At a teleconference, Wolfe and others announced a new Web site, wakeupdoctor.org. It contains a petition addressed to Thomas Nasca, M.D., ACGME executive director, and Rep. Henry Waxman (D-Calif.), chairman of the House Energy and Commerce Committee, and signed by some 48 national and regional patient-safety and consumer advocacy groups."

Make your voice heard where it matters.

 

[Law2Doc]

http://wakeupdoctor.org/

From an article in Modern Physician:

"At a teleconference, Wolfe and others announced a new Web site, wakeupdoctor.org. It contains a petition addressed to Thomas Nasca, M.D., ACGME executive director, and Rep. Henry Waxman (D-Calif.), chairman of the House Energy and Commerce Committee, and signed by some 48 national and regional patient-safety and consumer advocacy groups."

Make your voice heard where it matters.

Again, no studies have shown that reducing hours to 80 decreased error rates, so there's no reason to believe further reducing would improve things. The biggest error source is in the handoff, and you are increasing handoffs by decreasing hours. So if you want to work less hours, you really need to do it for non-patient safety reasons. Trying to allege that this is in the patient's interest is a farce. I'm all for decreasing hours if you do it for a reason you can say with a straight face.

Either reduce the hours because you are increasing the years of residency (not my favorite), or do it because you are making some sort of resident's rights argument. But don't waste anyone's time doing it in the name of safety. We already went down that road on the last reduction, and the results were no change. And that's the danger when you make a change not based on science but based on litigation pressure. Hard cases make bad law and this is a perfect example. Now is it better to be a resident after the 80 hour work week? Sure. Is the work more or less still getting done and are residents still getting trained fairly adequately? Sure. Is it better for patients? Nope -- the data doesn't show this. So keep the patient advocacy groups out of this, and push for this within the profession for resident quality of life reasons.

 

[TysonCook]

As posted in the other thread... As an attending I regularly work 60-80hr weeks, and so do my colleagues in other fields. Get used to the hours, because that is what is waiting for you at the "end of the tunnel".

Of course there are some fields that don't, but with the retiring baby boomer doctors, and 32,000,000 new patients, do you really think you are going to be working less???

 

[bluealiendoctor]

60-80hrs? How often do you do 30hr shifts in house? How often do you work Sat & Sun for 4 months straight? Get ready for the hours? Hell, we work more than you and make about 1/4 of your salary.........trust me there chief....we're ready.
Grass is always greener.

 

[TysonCook]

If you look at my sig, I just finished residency last year and I'm letting you know that it doesn't get much easier. Yes "chief" the pay is better, but don't be surprised if you're a junior member of your group and work all the weekends for 3 months straight, or 13/14 shifts in a row (or more), believe it or not you may not get weekends off for a year if that is what your group wants.

I'm just here to say that being an attending should be easier than being a resident, not harder. Of course no more 30hr shifts, I noted that in the other thread "chief".

 

[J1515]

I'm not signing it. You all knew what you signed up for, now stop your bitching. This is medicine, we're not teaching 3rd graders. We need the 80 hour work weeks. As L2D has said, instituting the 80 hr work week did not reduce mistakes. Stop crying about how tired you are, nobody cares. Doctors for the past 100 years have gone through the same thing, and they will continue to go through it for the next 100 years. We need the hours to maximize learning. Grow a set and stop whining.

 

[medsRus]

I'm not signing it. You all knew what you signed up for, now stop your bitching. This is medicine, we're not teaching 3rd graders. We need the 80 hour work weeks. As L2D has said, instituting the 80 hr work week did not reduce mistakes. Stop crying about how tired you are, nobody cares. Doctors for the past 100 years have gone through the same thing, and they will continue to go through it for the next 100 years. We need the hours to maximize learning. Grow a set and stop whining.

I don't necessarily like the notion that something was practices by our predecessors, and therefore, we must continue those ways. I'm sure that many horrific ideologies can be conjured, but I will refrain from rooting those evils in this forum.

 

[tno77]

The difference between doctors of 20 years ago who were training and those of us training now is that instead of spending 100+ hours a week taking care of patients, examining them, running and doing tests and performing interventions, we spend a significant portion of time writing notes and documentation (not neccessarily a bad thing), chasing after nurses to perform the tasks they were asked to do, chasing after social workers, nursing homes, shelters, government agencies for placement issues, in medical records fixing documents and clarifying charts for billing purposes, and hunting down fellows to do procedures

The end result is that patient contact is reduced, and the amount of hands-on learning is diminished.

 

[wild0ne]

The biggest error source is in the handoff, and you are increasing handoffs by decreasing hours.

Again, I'm not understanding why handoffs cannot be made more robust? If they are indeed the biggest source of errors, then shouldn't they be the focus?

If the hospitals were to hire a few more residents/attendings to buffer the time needed to perform a thorough/adequate handoff, why would that not work?

Yeah, it's not going to happen. There is zero financial incentive to do that (unless the threat of litigation provides one).

 

[wild0ne]

I'm not signing it. You all knew what you signed up for, now stop your bitching. This is medicine, we're not teaching 3rd graders. We need the 80 hour work weeks. As L2D has said, instituting the 80 hr work week did not reduce mistakes. Stop crying about how tired you are, nobody cares. Doctors for the past 100 years have gone through the same thing, and they will continue to go through it for the next 100 years. We need the hours to maximize learning. Grow a set and stop whining.

That's too bad.

Keep feeding your ego with the souls and vitality of your patients.

 

[J1515]

I don't necessarily like the notion that something was practices by our predecessors, and therefore, we must continue those ways. I'm sure that many horrific ideologies can be conjured, but I will refrain from rooting those evils in this forum.

I didn't say it should be done because doctors in the past did it. I meant doctors have been doing this forever and they turned out just fine. Patients aren't dropping dead left and right. There are plenty of things about the US healthcare system that are wrong, but the resident work hours are the least of the problems these days.

 

[J1515]

That's too bad.

Keep feeding your ego with the souls and vitality of your patients.

Oh please, cut the drama. None of my patients have been hurt. This has nothing to do with ego - in fact it's just the opposite. There are mountains of information I need to learn and I only have a few years to do so. I want the practice of medicine to be second nature to me by the time I finish residency and I want to learn as much as I humanly can over these next bunch of years. The only way that will occur is by maximizing my time in the hospital. Yeah it sucks not having a life, yeah it sucks occasionally walking around with big purple bags under my eyes, but I knew this is what it would be. As L2D has said, the 80 hour work week rule has not prevented any more mistakes than when residents used to work 100 hours. This petition has nothing to do with patient safety. It has to do with residents complaining that they're tired.

 

[Aphasic]

Many residents are having to fabricate their hours with the 80h-week, what will happen if it's even shorter? How long will residency be? 10 years? 15?

Personally, I'd rather work 80-100h/w and be done in 7y.

 

[Rocket777]

Again, no studies have shown that reducing hours to 80 decreased error rates, so there's no reason to believe further reducing would improve things. The biggest error source is in the handoff, and you are increasing handoffs by decreasing hours. So if you want to work less hours, you really need to do it for non-patient safety reasons. Trying to allege that this is in the patient's interest is a farce. I'm all for decreasing hours if you do it for a reason you can say with a straight face.

Either reduce the hours because you are increasing the years of residency (not my favorite), or do it because you are making some sort of resident's rights argument. But don't waste anyone's time doing it in the name of safety. We already went down that road on the last reduction, and the results were no change. And that's the danger when you make a change not based on science but based on litigation pressure. Hard cases make bad law and this is a perfect example. Now is it better to be a resident after the 80 hour work week? Sure. Is the work more or less still getting done and are residents still getting trained fairly adequately? Sure. Is it better for patients? Nope -- the data doesn't show this. So keep the patient advocacy groups out of this, and push for this within the profession for resident quality of life reasons.

I would disagree that there are no studies showing patient benefit from the 80-hr work week.

1) Impact of the 80-hour work week on mortality and morbidity in trauma
Morrison CA, Wyatt MM, Carrick MM.
J Surg Res. 2009 Jun 1;154(1):157-62. Epub 2008 Jul 9

2) Impact of duty hours restrictions on quality of care and clinical outcomes.
Bhavsar J, Montgomery D, Li J, Kline-Rogers E, Saab F, Motivala A, Froehlich JB, Parekh V, Del Valle J, Eagle KA.
Am J Med. 2007 Nov;120(11):968-74.

3)
Changes in outcomes for internal medicine inpatients after work-hour regulations.
Horwitz LI, Kosiborod M, Lin Z, Krumholz HM.
Ann Intern Med. 2007 Jul 17;147(2):97-103. Epub 2007 Jun 4.

4) Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.
Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH.
JAMA. 2007 Sep 5;298(9):975-83.

(This one shows no difference - provided for different conclusions)

5) Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.
Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH.
JAMA. 2007 Sep 5;298(9):984-92.

6) The 80-hour resident workweek does not adversely affect patient outcomes or resident education.
de Virgilio C, Yaghoubian A, Lewis RJ, Stabile BE, Putnam BA.
Curr Surg. 2006 Nov-Dec;63(6):435-9; discussion 440.

7)
Changes in hospital mortality associated with residency work-hour regulations.
Shetty KD, Bhattacharya J.
Ann Intern Med. 2007 Jul 17;147(2):73-80. Epub 2007 Jun 4.


I don't know what the right answer is, but the fact is that there is a large body of literature on this subject, and a good amount of that body points to improvements in patient care. And some of it points in the other direction. I'd like to be able to correlate conclusions with age of author, that would be interested.

 

[SoCuteMD]

If you look at my sig, I just finished residency last year and I'm letting you know that it doesn't get much easier. Yes "chief" the pay is better, but don't be surprised if you're a junior member of your group and work all the weekends for 3 months straight, or 13/14 shifts in a row (or more), believe it or not you may not get weekends off for a year if that is what your group wants.

I'm just here to say that being an attending should be easier than being a resident, not harder. Of course no more 30hr shifts, I noted that in the other thread "chief".

60-80 hours a week as an EM attending? REALLY? Are you junior faculty somewhere and including clinical, research, and teaching obligations? How many 12s a week ARE you working?

 

[MojoRisin]

I asked one of the senior attendings about this during my subI, mainly asking if residents are coming out as adequately trained now as then. He said they are, but the learning curve has been drawn out a little bit.

If hours are cut much more our residencies are going to have to become longer in order for adequate training. I do not want to be in residency for >5 years, I will already be in my 30s before I am out.

 

[Substance]

Residents should never be required to provide patient care in a state of mental and physical exhaustion.

Even if there is no "evidence" to show that patient error is not increased with resident fatigue, the fact that airline pilots and truckers have work-hour restrictions, as well as laws in certain jurisdictions that state that driving while under extreme fatigue is equivalent to a DUI, show that inhumane work hours are not in the benefit of the resident and that society believes that being too tired puts you in poor shape to perform tasks which may endanger others.

I would go as far as saying that in non-surgical programs, residency would not have to be lengthened at all. There'd be more time for reading and debate, which would be as or more valuable than super-scutting out your 100th midnight failure-to-cope. Surgical programs may require an increase in time because of the actual hours required to become an expert at their physical abilities. Or they could be streamlined so that surgeons operate more and scut less. Heck, those NPs who pipe up about being equivalent to doctors...give them the floor scut for 70k/yr. Bingo.

So, if residency may need to be extended, then medical school should be shortened. There are schools in Canada that have 3-year programs, and these schools graduate physicians that are as good as their 4-year counterparts. Lots of medical school could be excised, especially the touchy-feely bits that are essentially useless.(its of my opinion that the current Flexner framework for medical education is antiquated and needs complete revision)

 

[Coastie]

The day I trust or support anything from Henry Waxman is the day Obama governs from the principles which made America great.

In other words, never. Petition fail.

http://wakeupdoctor.org/

From an article in Modern Physician:

"At a teleconference, Wolfe and others announced a new Web site, wakeupdoctor.org. It contains a petition addressed to Thomas Nasca, M.D., ACGME executive director, and Rep. Henry Waxman (D-Calif.), chairman of the House Energy and Commerce Committee, and signed by some 48 national and regional patient-safety and consumer advocacy groups."

Make your voice heard where it matters.

 

[wild0ne]

Many residents are having to fabricate their hours with the 80h-week, what will happen if it's even shorter? How long will residency be? 10 years? 15?

Personally, I'd rather work 80-100h/w and be done in 7y.

Again, why is there necessarily a tradeoff between shorter working hours and longer residency training?

What percentage of your day are you actually learning and/or applying your medical knowledge?

Instead of extending training, how about simply making it more efficient by cutting out all the administrative work? If hospitals hired resident's assistants (many now do) to handle this type of work, residents' days would be more high yield. You could even shorten training years.

Oh yeah, this would cost money, and why would hospitals want to do that when they have highly intelligent, hardworking resident's working for $45/year - and almost begging for it.

But, that's not part of the multiple choice answers given to you by the hospital, is it? It's always: Reduced hours leads to: a) longer training, b) less learning, c) increased handoffs, d) all of the above.

To put it another way:

If your state is in financial trouble, and the local politician says that taxes must be raised to prevent job losses or public service cuts...what's your natural reaction? Sure ... throw more money at the problem? Or, trim the fat and use what money you have more effectively?

Resident's spend more than enough time in the hospital to learn medicine. There is no need to extend training, for any reason.

 

[Law2Doc]

Again, I'm not understanding why handoffs cannot be made more robust? If they are indeed the biggest source of errors, then shouldn't they be the focus?

If the hospitals were to hire a few more residents/attendings to buffer the time needed to perform a thorough/adequate handoff, why would that not work?
...

Here's the way it usually plays out. You are at work from 6am. Morning starts with rounding, and various other time killers. The latter half of the day you are spending scrambling to get everything done that needs to get done before you leave that day so as not to stick it to the night shift. All the while you are frantically running around answering pages that distract you from your mission, admitting patients, trying to discharge others. Before you know it it's about 6-7pm and you have it all in some semblance of a controllable order. So you find the person you need to sign off to, and want to sign off to get out of there. If you have a busy service or are carrying multiple pagers, the number of patients can be 30-50. Mind you, you have already been there for 13 hours and are anxious to get out of there because another bunch of 13+ hour days are looming in front of you that week, plus call. So you need to give the night person exactly what they need to get by, but not spend so much time per patient that you are stuck for another 1+ hours. So that really means about a minute a patient. Not always enough time to do it justice, but if you spent more time, you'd get out of there at 8pm each night, which would quickly run you afoul of hour requirements.. So that's the real issue with more detailed signouts -- that is the point where you are pushing the duty hour limits for many people. Well, you might say, then just have sign-out happen earlier and go for longer, but then you end up not getting everything done, dumping more on the night folks who already have the hard task of picking up the loose ends on a lot of patients they don't really know, and it just shifts the risk errors to another place. The problem is that residents tend to be fairly thinly spread as is, are covering a lot of patients, and have a lot to do each day. So things like sign-out need to be abbreviated to the bare minimum to accomplish what needs to be accomplished during the day and get folks out at a reasonable time.

Hiring more people to buffer the handoffs, aside from being logistically problematic because programs don't get to arbitrarilly decide this, creates more people who need to be handed off to (ie more handoffs, perhaps with fewer patients) -- bear in mind that this isn't piece work-- everyone who functions as a resident has to be up to speed. So that introduces even more instances for errors to be made. Not the right approach IMHO.

 

[staylor21]

Again, why is there necessarily a tradeoff between shorter working hours and longer residency training?

What percentage of your day are you actually learning and/or applying your medical knowledge?

Instead of extending training, how about simply making it more efficient by cutting out all the administrative work? If hospitals hired resident's assistants (many now do) to handle this type of work, residents' days would be more high yield. You could even shorten training years.

Oh yeah, this would cost money, and why would hospitals want to do that when they have highly intelligent, hardworking resident's working for $45/year - and almost begging for it.

But, that's not part of the multiple choice answers given to you by the hospital, is it? It's always: Reduced hours leads to: a) longer training, b) less learning, c) increased handoffs, d) all of the above.

To put it another way:

If your state is in financial trouble, and the local politician says that taxes must be raised to prevent job losses or public service cuts...what's your natural reaction? Sure ... throw more money at the problem? Or, trim the fat and use what money you have more effectively?

Resident's spend more than enough time in the hospital to learn medicine. There is no need to extend training, for any reason.

Granted there's a lot of wasted time. But to think that cutting the work week from 80 to 60 will have no effect on education relies on two assumptions:

1) That 25% of time currently spent is noneducational
2) That a move to a 60 hour work week will completely "cut out the fat."

I highly doubt that (1) and (2) will be universally true.

For those who think a shorter work week will have no effect on learning, one question I have is this: from my observations, universally, the "better" residents tend to be those who put in more time. Now granted, they may be more efficient too, but that only takes them so far--at the end of the day, they're better because they're putting in extra time that others aren't. If that's true, why are people so willing to believe that a resident who puts in 60 hours/wk will be just as good as the one who puts in 80?

 

[staylor21]

Here's the way it usually plays out. You are at work from 6am. Morning starts with rounding, and various other time killers. The latter half of the day you are spending scrambling to get everything done that needs to get done before you leave that day so as not to stick it to the night shift. All the while you are frantically running around answering pages that distract you from your mission, admitting patients, trying to discharge others. Before you know it it's about 6-7pm and you have it all in some semblance of a controllable order. So you find the person you need to sign off to, and want to sign off to get out of there. If you have a busy service or are carrying multiple pagers, the number of patients can be 30-50. Mind you, you have already been there for 13 hours and are anxious to get out of there because another bunch of 13+ hour days are looming in front of you that week, plus call. So you need to give the night person exactly what they need to get by, but not spend so much time per patient that you are stuck for another 1+ hours. So that really means about a minute a patient. Not always enough time to do it justice, but if you spent more time, you'd get out of there at 8pm each night, which would quickly run you afoul of hour requirements.. So that's the real issue with more detailed signouts -- that is the point where you are pushing the duty hour limits for many people. Well, you might say, then just have sign-out happen earlier and go for longer, but then you end up not getting everything done, dumping more on the night folks who already have the hard task of picking up the loose ends on a lot of patients they don't really know, and it just shifts the risk errors to another place. The problem is that residents tend to be fairly thinly spread as is, are covering a lot of patients, and have a lot to do each day. So things like sign-out need to be abbreviated to the bare minimum to accomplish what needs to be accomplished during the day and get folks out at a reasonable time.

Hiring more people to buffer the handoffs, aside from being logistically problematic because programs don't get to arbitrarilly decide this, creates more people who need to be handed off to (ie more handoffs, perhaps with fewer patients) -- bear in mind that this isn't piece work-- everyone who functions as a resident has to be up to speed. So that introduces even more instances for errors to be made. Not the right approach IMHO.

The one way to get around the scenario you present is simply to cap teaching services at smaller census--instead of the 30-50pts you mention, perhaps structure things so that a guy only has say 10 patients--now, he can spend more time on each one.

This of course require hiring a lot more people--attendings, midlevels, and residents.

 

[dutchman]

If you really want to reduce work hours, send not petitions to politicians and slave traders(ACGME). Send specific exhaustion related error stories to lawyers and aggresive pt advocacy groups. Let them go and argue in court in front of NORMAL human beings that sleep deprivation does not increase medical errors.

 

[Substance]

If you really want to reduce work hours, send not petitions to politicians and slave traders(ACGME). Send specific exhaustion related error stories to lawyers and aggresive pt advocacy groups. Let them go and argue in court in front of NORMAL human beings that sleep deprivation does not increase medical errors.

Amen.

 

[Slack3r]

I'm not signing it. You all knew what you signed up for, now stop your bitching. This is medicine, we're not teaching 3rd graders. We need the 80 hour work weeks. As L2D has said, instituting the 80 hr work week did not reduce mistakes. Stop crying about how tired you are, nobody cares. Doctors for the past 100 years have gone through the same thing, and they will continue to go through it for the next 100 years. We need the hours to maximize learning. Grow a set and stop whining.

 

[mig26x]

In august of 2009 when I was doing my MICU rotation I left my 30 hour call (It went into 32hours) and got into the elevator, there was this middle age guy and the conversation went like this:
guy: How long have you been here?
me: since 8am yesterday
guy: they still have that sh-it of staying overnight in the hospital?
me: yes ( i was tired, therefore not very into the conversation)
guy: thats wrong, thats bad for patient saftey. Im a truck driver and by law I have to take a break between X amount of hours ( I dont remember right now because again i was tired) and if we dont do we get fined or the company gets fined. My company is very strict about this law

at that point elevator door open and I left my way.

There have been studies that showed that after 24 hours of sleep deprivation is the same as been legally drunk.

to be honest, i really dont know what's best for residency training right now--> to keep it at 80/30 and same length of trainig vs less hours with more years.

 

[wild0ne]

Again, no studies have shown that reducing hours to 80 decreased error rates, so there's no reason to believe further reducing would improve things.

Landrigan CP et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. NEJM. 2004;351:1838-1848.

Here's a few more (from the petition website, btw):

- Lockley SW et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. NEJM. 2004;351:1838-1848.

- Arnedt T et al. Neurobehavioral Performance of Residents After Heavy Night Call vs After Alcohol Ingestion. JAMA. 2005;294:1025-1033.

- Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. SLEEP. 2005; 28(11):1392-1402.

Let me guess, "You need me on that wall".

 

[J ROD]

I vote for no shift longer than 16-18hrs...

I dont care about the 80hrs/wk.....works for me...

I just think 30hrs straight makes no sense...after all we are in healthcare and know the negative impacts....plus, it is not like we are not human and not subject to the normal human needs like sleep.

I have done 24+hrs a couple of times and it was hard.....I did feel mentally drunk and had a hard time getting my thoughts together.....

sounds like a great idea to let someone like that care for others and potentially have lives in their hands....😱